ORIGINAL ARTICLE

Study of Medication Prescribed and Appropriateness of Antimi-

crobials in Hospitalized Respiratory Tract Infectious Children in
Tertiary Care Teaching Hospital, Western Nepal
Sudarshan Raj Dhakal1, Bijay Kafle2, Bishal Udas3, Pabitra Duwadi3, Ram Poudel4, Rinky Palikhe4, Kadir Alam5, Gulam
Muhammad Khan6
1
Lomus Pharmaceutical Private Limited, Kathmandu, Nepal, 2Kaski Sewa Hospital, Pokhara, Nepal, 3Shradha Institute of Health Science, Nepal, 4Western Acad-
emy of Health Science, Nepal, 5Department of Clinical Pharmacology and Therapeutics, BPKHIS, Dharan, Nepal, 6Pokhara University, Pokhara, Nepal

ABSTRACT (MAI) was 3.29. The mean MAI per prescription was found to be 1.69 ± 0.47. 33
(31.43%) of the samples were found to be appropriate and 72 (68.57%) sample
Background: Respiratory Tract Infection (RTI) is the global cause of death were found to be inappropriate.
in children. Nepal, India, Indonesia and Bangladesh account 40% of the
global cause. Antimicrobials are the most commonly prescribed drugs in Key words: Respiratory tract infection, antimicrobials, appropriateness,
hospitals whose appropriateness solely relies on its rational use. Methods: inappropriateness, medication appropriateness index
A cross-sectional study was carried out in pediatric in-patients suffering from
the respiratory infection at a tertiary care teaching hospital. WHO/INRUD
prescribing indicators and appropriateness index were used in determination
of the drug prescribing indicators and appropriateness of antimicrobials.
Results: A total of 108 samples male incidence were higher than female. The
maximum samples were found in between the age group 1-5 years. Brahaman Correspondence:
and Chhetri were the found in larger frequency. Bronchopneumonia 67 and Access this article online
Sudarshan Raj Dhakal,
Acute Bronchiolitis 21 (19.4%) were the most common diagnosis. Cefotaxime Masters in Pharmaceutical Sciences, Website: www.jbclinpharm.org
was the drug found to be used in maximum number 81 (54.4%) following Lomus Pharmaceutical Private Limited, Quick Response Code:
Gentamicin and Amoxy-Clav. In 58 (53.7%) sample Cephalosporin were used Kathmandu, Nepal.
as single drug, following its combination with aminoglycosides 20 (18.6%) E-mail: sudarshanrazz@gmail.com
Out of which cefotaxime and gentamicin combination was found to be in 15
samples. In discharged medication 70.3% of the samples were prescribed with
Cephalosporin. The average no of drug per prescription were found to be 4.31.
7.7% of the drugs were found to be prescribed in generic name. The antibiotic
encounter per samples and medication from essential drug list were found to be
100%. Conclusion: Total of 140 antibiotics were assessed for appropriateness
where 50 (35.71%) of antibiotics were found to be appropriate and 90 (64.29%)
were found to be inappropriate. The average Medication Inappropriateness

BACKGROUND
Respiratory tract infections is the worldwide main cause of death in
children aging less than 5 years and which produce 8.2% of the total
disease burden. In developed countries respiratory tract infections
are the leading cause of morbidity, accounted for 20% of medical
consultation.[1] The pediatric population comprises of 20-25% of the
total world population, and numerous acute and chronic diseases can
effect this sub population. Antibiotics are among the most frequently
prescribed classes of medications for children.[2] It is estimated that
Bangladesh, India, Indonesia and Nepal together account for 40%
of global acute respiratory infection mortality.[3] Acute respiratory
infection (ARI) is one of the leading causes of childhood morbidity
and mortality in Pakistan. To achieve the reduction in the death rate
attributed to pneumonia, WHO’s standard ARI case management
guidelines were adopted to act in rationalization of the drug use.[4]
Children are particularly challenging group of patients when trying
to ensure the safe use of medication. Children are challenging groups
and the most important target group for the effort aimed at reducing
unnecessary antibiotic use as they receive significant proportion of
antibiotics.[5] Upper respiratory tract infection (URTI) is considered
as one of the major public health problems. The greatest problem
for developing countries is the mortality from URTI in children
less than five year of age.[6] Common cold, sore throat, croup,
bronchiolitis, pharyngotonsillitis and pneumonia are the common
respiratory infection. WHO recognized respiratory diseases as the
second important cause of death for children under five years in 2010.
[7]
Antibiotic are precious but non-renewable resources which are of
major benefit to people who have serious and life threatening bacterial
infections. Squandering this resources use 97% agreed that “overuse
of antibiotics is a major factor contributing to the development of
antibiotic resistance.” Prior antibiotic use increases the risk that a
child will develop a resistant infection” 78% and that “resistance has
resulted in treatment failure for children with URIs are 69%.[8,9] The
inappropriate use of antibiotics alarms a significant global public health
problem. Inappropriate prescription by both the trained and untrained
health care workers where no proven benefit of the therapy may lead to
the microbial resistance.[10,11]
Improved patient understanding of the etiology of these infections,
and improved compliance where antibiotic therapy is indicated, are of
paramount importance.[12] In the developing world effective health care
interventions are underutilized, and income-related disparities in use
are found in lager extend. Antibiotic drug overuse and inappropriate
antibiotic drug selection are associated with increased drug resistance
among respiratory pathogens which results in increased treatment
costs.[13] Awareness of clinical manifestations that help differentiate
viral from bacterial infection and the use of guidelines can promote the
appropriate management of respiratory tract infections.[14]
One of the research found out that 16% of antibiotic were prescribed
in upper respiratory tract infection, pneumonia and cough/bronchitis
were prescribed with 78% and 28% respectively in each of the cases.
[15]
Regarding the cost Antimicrobials are among the most commonly
This is an open access article distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix,
tweak, and build upon the work non‑commercially, as long as the author is credited
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For reprints contact: invoice@jbclinpharm.org
Cite this article as: Dhakal SR, Kafle B, Udas B, Duwadi P, Poudel R, Palikhe
R, Alam K, Khan GM. Study of Medication Prescribed and Appropriateness of
Antimicrobials in Hospitalized Respiratory Tract Infectious Children in Tertiary
Care Teaching Hospital, Western Nepal. J Basic Clin Pharma 2018;9:35-40.

35 © 2018 Journal of Basic and Clinical Pharmacy

 Dhakal SR, et al.: Study of Medication Prescribed and Appropriateness of Antimicrobials in
Hospitalized Respiratory Tract Infectious Children in Tertiary Care Teaching Hospital, Western Nepal.
prescribed drugs in hospital that account for over 50% of total
value of drugs sold in the country.[16] Over prescribing of antibiotics
Sociocultural and economic pressures, Malpractice litigation concerns:
there is a rapid course for some bacterial diseases that are preceded by
viral illness and patients may not return if illness worsens or persists
and meeting parent expectations: dissatisfied parents may seek care
elsewhere[17] “Prior antibiotic use increases the risk that a child will
develop a resistant infection” 78% and that “resistance has resulted in
treatment failure for children with URIs are 69%.[9] Prudent antibiotic
use is only option to delay the development of resistance, because of
few new antibiotics in the Research and Development.[18]
METHODS
Study design
A cross-sectional study was conducted in which patients taking
medication during the treatment were observed.[19,20]
Study site
The study was conducted Manipal Teaching Hospital (MTH) a 700
bedded multidisciplinary tertiary care teaching hospital located in
Pokhara City, western Nepal. Average of 500 outpatients visit hospital
per day and with about 250 bed occupancy.[21]
Study setting
The study was conducted in the pediatric inpatient of Manipal Teaching
Hospital. Entire patient admitted in the pediatric ward for treatment
of respiratory tract infection were taken. Antimicrobial prescribed for
the treatment of respiratory tract infection for children will be taken in
considerations.
Study duration
The Study was carried out for period of six month which included time
for the literature review, data collection and data analysis. The actual
time for data collection was ten weeks.
Sampling techniques
The prescriptions were taken and/or the details were followed till
discharge of the patients. The data for present study was collected by
chart review method. During the study inpatients case records was
reviewed, which included patients case history, diagnosis, physician
medication order sheets, nurse medication administration records,
progress chart, laboratory investigations and report of other diagnostic
tests. This information was documented in the patient profile form. All
the prescription documented were analyzed for following parameters
such as demographic status of patients, disease diagnosis, the medication
used during the treatment, appropriateness of antimicrobials and
assessment of cost. All data are represented in percentage.
Sample size
Sample size is calculated by using the formulae (WHO, 2001) where,
N=Z2p (1-p)/D2
Where, N=approximate sample size; Z=Z value at a given confidence
interval; D=Margin of error.
Inclusion and exclusion criteria
All the Respiratory inpatients in pediatric ward of Manipal Teaching
Hospital, Phulbari, Pokhara, Nepal, were taken. Critically ill, patients
receiving antimicrobial from out-patient pharmacy, children below
one year and other admitted pediatric patients beside respiratory
illness were excluded. The patients transferred to ICU were not further
followed.
Journal of Basic and Clinical Pharmacy, Vol 9, Issue 1, Dec-Feb, 2018
Data collection
Data were collected after obtaining written consent), using patient
profile form which included demographic status of patients, disease
diagnosis, the medication used during the treatment, appropriateness
of antimicrobials and assessment of cost for the period of ten weeks.
Patient those transferred to ICU during the study period were not
followed.
Criteria and methods for data collection
The Criteria for assessing used was the WHO/INRUD prescribing
indicators and medication appropriateness index the tool developed
by Hanlon et al. and Samsa et al.[22,23] was used after the permission
being granted which consists of ten purviews: indication, effectiveness,
dosage, correct directions, practical directions, drug-drug interactions,
drug-disease interactions, duplication, duration and expense. The
assessment of antibiotics appropriateness was done by the committee
formed which consists of a group of physician and clinical pharmacist.
Regarding the guideline Clinical practice guidelines on pneumonia and
respiratory tract infections in children was used (URL-1).
Data collection tools
These tools are the self-developed forms that are used to document the
evidence during the research procedure. Descriptive analysis was done
by using SPSS Version 20. The ethical approval for the research was
obtained from Ethical Research Board of Manipal Teaching Hospital.
RESULTS
A total of 108 samples who met the inclusion criteria were selected and
were followed for the present study. The cases were analyzed bases upon
the following parameters. Among 108 total samples taken for the study
65 (60.2%) were male and 43 (39.8%) were female [Table 1]. The highest
range includes age group in-between 1-5 years i.e., 92% following the
age group 6-10 years. The lowest no ranges in-between the age group
11-15 years [Table 2]. The mean age was found to be 2.5975 ± 2.64364.
Brahaman 34 (31.5%) were found to be the highest frequency following
Chhetri 27 (25%), Janajati 24(22.2%), Dalit 18 (16.7%) and Newar 5
(4.6%) respectively [Figure 1]. The most commonly diagnosed case out
of 108 samples was bronchopneumonia, 64 (62%), following Acute
Bronchiolitis 21 (19.4), Bronchial Asthma 8 (7.4%) Pharyngotonsilitis
5 (4.6%), CROUP 4 (3.7) and Cough along with fever 3 (2.8%) [Figure 2].
Antibiotic used during stay
A total of 149 antibiotics were found to be used, out of which
Cefotaxime was found to be the drug used in highest frequency i.e., 81
(54.5%) following by the gentamycin 20 (13.4%). Cephalosporin (92
(62%)) was the antibiotic found to be used in larger number following
Aminoglycosides and Penicillin antibiotics, 27 (18%) and 24 (16.1%)
respectively. Each sample consists of 1.38 ± 0.62 antibiotics and 1.367
± 0.99 injections [Table 3].
Table 1: Demographic Status of the patients
Gender Total Sample Percent
Male 65 60.2
Female 43 39.8
Total 108 100
Table 2: Age-wise distribution
Age Group (Years) Frequency Percent
1-5 92 85.2
6-10 13 12
11-15 3 2.8
Total 108 100.0
36
 Dhakal SR, et al.: Study of Medication Prescribed and Appropriateness of Antimicrobials in
Hospitalized Respiratory Tract Infectious Children in Tertiary Care Teaching Hospital, Western Nepal.

Ethnic Distribution

Chhetri
Brahaman
Newar
Series 1, Brahaman,
Janajati
34
Series 1, Chhetri, 27 Dalits
Series 1, Janajati, 24
Series 1, Dalits, 18

Series 1, Newar, 5

Figure 1: Ethnic Distribution

Frequency, Frequency, Frequency, Acute

Cough/Fever, 3, 3% Pharyngotonsilitis, Bronchiolitis, 21,
5, 5% 19%

Frequency (n=108)
Acute Bronchiolitis

Frequency, CROUP,
CROUP4, 4%

Frequency,
Bronchial Asthma,
Asthma 8,
7%

Bronchopneumonia

Cough/Fever
Frequency,
Bronchopneumonia,
67, 62% Pharyngotonsilitis

Figure 2: Distribution according to diagnosis

No of antibiotic used Other medications prescribed during stay

Out of the total sample 108, 74 (68.5%) consist of single antibiotic
whereas 28 (25.9%) were prescribed with two antibiotics. Similarly, 4
prescriptions were found prescribed with multiple antibiotics [Figure
3]. Table 4 explains that the Combination of Cephalosporin and
Aminoglycoside found to be used in greater amount i.e., 20 (22.2%) of
the total patient prescription.
A total of 316 medications beside antibiotics were found to be used
during the study period. Out of which Inhalant, NSAIDs were used in
large no of patients [Table 5].
Antibiotic on discharge
Single drug antibiotic was found to be used in all of the cases were
cephalosporin 76 (70.30%) being the highest no of prescription

Journal of Basic and Clinical Pharmacy, Vol 9, Issue 1, Dec-Feb, 2018 37

 Dhakal SR, et al.: Study of Medication Prescribed and Appropriateness of Antimicrobials in
Hospitalized Respiratory Tract Infectious Children in Tertiary Care Teaching Hospital, Western Nepal.
Frequency
Frequency,
Single
Antibiotic, 74
Frequency, Two
Antibiotic, 28
Figure 3: Number of Antibiotics
followed by penicillin antibiotic and 16 (14.8%) respectively. Out of
remaining ten samples three of them were transferred to intensive care
unit and remaining seven parents’ opted to take their child home at
their own risk [Table 6].
The average number of drug per prescription was found to be 4.31 ±
1.51. Higher than that of WHO/INRUD standard. Similarly 7.7% of
the drugs were found to be prescribed by generic name. The percentage
of encounter prescribed as injection was found to be 38.71%. All the
samples were found to be prescribed with antibiotic [Table 1]. The
medication appropriateness was determined by the committee of
health professionals including doctors and clinical pharmacists. Out of
the total 140 antibiotic accessed 50 (35.71%) of antibiotics were found
to be appropriate whereas remaining 90 (64.29%) of the antibiotics
were found to be inappropriate. The average MAI score was found
to be 3.29. Mean MAI per Prescription was found to be 1.69 ± 0.47.
Overall sample appropriateness was found to be 33 (31.43%) and
inappropriateness was found to be 72 (68.57)% [Tables 7 and 8].
DISCUSSION
The number of male incidence was found to be higher in the study
65 (60.2%). Similar result was seen in the research done by Rijal et al.
and Munir[24,25] where the incident of male were found to be 58.1% and
64.2% respectively. The highest percentage of age group being affected
were found to be in-between 1-5 years of age i.e., 85.2%. In another
research done by Duarte et al.[26] found to be 52.1%. Although impact
being the same. The higher incidence of male greater than female is
explained by NIPORT 2005, as may be due to genetic or there may be
higher reporting for boys due to gender bias where mothers may be
considering it more serious for boys or it is considered less serious for
girls.
Journal of Basic and Clinical Pharmacy, Vol 9, Issue 1, Dec-Feb, 2018
Single Antibiotic
Two Antibiotic
Multiple Antibiotic
Frequency,
Multiple
Antibiotic, 4
There is also evidence that women receive different care than men for
common chronic disorders, while they make more visits to physicians
for acute, self-limited diseases. Nevertheless, females live longer
than males in most populations.[27] The discrepancy in distribution
of respiratory tract infection among various ethnic groups could
be attributed to their social, cultural and religious background not
mentioning the inequality in access to services and in the range of
opportunities available.[28] Maigolis et al. suggests that there is evidence
that highly educated families are more likely than less-educated
families to report respiratory symptoms. It also indicate that much of
the effect of socioeconomic status can be explained by factors that are
related to the infant’s home environment, most of which are mutable
(exposure to tobacco smoke, crowding, stress, low birth weight, and
bottle feeding). In addition, exposure to risk factors for respiratory
illness is not only more common among families of low socioeconomic
status, but the effect of the exposure also seems to be the greatest in this
group, at least among infants not in day care.[28]
A total of 149 antibiotics were found to be used in the study during the
treatment phase. Where, Cephalosporin 53.7% was the drug found to be
used in most of the cases following its combination with aminoglycosides
18.6% and penicillin 16.7% respectively. Cephalosporins were the
most often prescribed class of antimicrobials (56.36%) followed by
Penicillins (40.36%) and Aminoglycosides (36.36%). Injection was the
commonest route of administration (58.25%). Lower respiratory tract
infection was the commonest diagnosis[29] by Ramesh et al. Another
research showed that Cephalosporin 92 (62%) was the antibiotic found
to be used in larger number following Aminoglycosides and Penicillin
antibiotics.[30] Broad-spectrum antibiotics were the most commonly
prescribed antibiotic class in hospitals, namely third generation
Cephalosporin.[31] Pneumonia was the most prevalent diagnosis among
infant. During the treatment the combination of aminoglycosides and
38
 Dhakal SR, et al.: Study of Medication Prescribed and Appropriateness of Antimicrobials in
Hospitalized Respiratory Tract Infectious Children in Tertiary Care Teaching Hospital, Western Nepal.
Table 3: Antibiotic used during the stay cephalosporin was found to be 20 (18.6%) out of which 15 (75)% of this
Antibiotic Frequency Percentage combination consists of Cefotaxime and Gentamicin. Similar result
Cefotaxime 81 54.4 was seen in study by other scholars.[32]
Cefpodoxime 2 1.3 The average MAI score obtained was 3.29. Out of the total 140
Cefixime 1 0.7 antibiotic accessed 50 (35.71%) of antibiotics were found to be
Ceftriaxone 5 3.4 appropriate whereas remaining 92 (64.29%) of the antibiotics were
Flucloxacillin 2 1.3 found to be inappropriate. In total sample done for determination of
Ceftazidime 3 2.0 appropriateness, the mean MAI was found to be 1.69 ± 0.47, where
Amoxy-Clav 13 8.7 33 (31.43%) were found to be appropriate and remaining 72 (68.57%)
Ampicillin 9 6.1
were found inappropriate. In another study the rate of indication
appropriateness for inpatients was 1637/2070 (79.0%). Inappropriate
Azithromycin 2 1.3
dosing which encountered in internal ward being a result of failing
Gentamycin 20 13.4
to tailor pharmacotherapy for each individual.[33] Another results
Vancomycin 2 1.3
indicated that 56.3% of total patients on antimicrobials were judged
Amikacin 4 2.7 as inappropriate (56.8% with antimicrobial therapy and 55.9% with
Mupirocin 3 2.0 antimicrobial prophylaxis).[34] In one of the study provide information
Tobramicin 1 0.7 that even though prescribing practices has improved, a high rate of
Ciprofloxacin 1 0.7 inappropriate antibiotic prescribing continues. Almost half of patients
Total 149 100 with upper respiratory tract infections receive antibiotics.[35] In a research
done by West et al.[36] a total of 3131 drugs (44.9%) were considered
Table 4: Group of Antibiotic used to be appropriate out of which 56 drugs were marginally appropriate,
Antibiotic Group Frequency Percentage whilst 55.1% (n=384) of drugs were prescribed inappropriately, i.e.,
Cephalosporin 58 53.7
55.1% of drugs met one or more criteria of the MAI. The results of this
study show that 55.1% of the drugs prescribed during this study, based
Penicillin 18 16.7
on MAI criteria, were inappropriate for one reason or another. In one
Cephalosporin+Aminoglycosides 20 18.6
of the research done in Nepal the appropriateness of antimicrobial was
Cephalosporin+Macrolides 2 1.8
found to be 31.7%.[37]
Cephalosporin+Penicillin 2 1.8
Cephalosporin+Monocarboxyllic Acid 3 2.8 Limitation of the study
Penicillin+Aminoglycoside 3 2.8 ►►The research was carried out for the short duration of time period.
Cephalosporin+Aminoglycosides+Penicillin 1 0.9
►►Children below one year were not taken in the study.
Cephalosporin+Aminoglycosides+Fluoroquino
1 0.9
lones ►►Due the absence of the standard treatment guideline, the guideline
Total 108 100 validated by the physicians was taken in consideration.

Table 5: Others medication during stay ►►The research was carried out in only one pediatric inpatient of a
hospital. Therefore the result might not be extrapolated to the
Other Medication Frequency Percentage other teaching hospital.
Inhalant 103 95.4
Metered Dose Inhaler 4 3.7 CONCLUSION
Anti-histamine 5 4.6
Prescribing higher generation antibiotics and duplication with
Corticosteroid 13 12
antibiotics were common types of inappropriateness. Similarly
H2-Blockers 16 14.8 antibiotics alone account 76.08% of the medication cost. 50 (35.71%)
Local Applicant 5 4.6 of antibiotics were found to be appropriate and 90 (64.29%) were found
Nasal Decongesant 20 18.5 to be inappropriate. The average Medication Inappropriateness (MAI)
Anti-Diarrhoeal 13 7.4 was 3.29. The mean MAI per prescription was found to be 1.69 ± 0.47. 33
Cough Suppressant 11 10.2 (31.43%) of the samples were found to be appropriate and 72 (68.57%)
NSAIDs 95 88 sample were found to be inappropriateness. The use of antimicrobial
Anti-emetic 7 6.5 was found to be prescribed in 100% of the cases of Respiratory Tract
Others 24 22.2 Infection. The cases of inappropriateness were found to be higher than
that of appropriateness which shows the requirement in improvement
Table 6: Antibiotic on discharge in rationalization of antibiotics.
Antibiotics Frequency Percentage
Abbreviations
Cefpodoxime 67 62
Ampicillin 1 0.9 ARI: Acute Respiratory Infection; RTI: Respiratory Tract Infection;
Amoxicillin 7 6.5 URTIs: Upper Respiratory Tract Infections; LRTIS: Lower Respiratory
Amoxy-Clav 8 7.4 Tract Infections; CXR: Chest Radiography; GERD: Gastro esophageal
Cefixime 8 7.4 Reflux Disease; GAS: Group-A Streptococcus; CAP: Community
Cefuroxime 1 0.9 Acquired Pneumonia; HAP: Hospital Acquired Pneumonia; NSAIDs:
No Antibiotic 6 5.6 Non-Steroidal Anti Inflammatory Drug; RSV: Respiratory Syncytial
Total 99 90.7 Virus; WHO: World Health Organization; INRUD: International
Left Against Medical Advice 7 6.5
Network for Rational Use of Drugs; MTH: Manipal Teaching Hospital;
Transferred to ICU 3 2.8
US: United States.

Journal of Basic and Clinical Pharmacy, Vol 9, Issue 1, Dec-Feb, 2018 39

 Dhakal SR, et al.: Study of Medication Prescribed and Appropriateness of Antimicrobials in
Hospitalized Respiratory Tract Infectious Children in Tertiary Care Teaching Hospital, Western Nepal.
Table 7: WHO/INRUD Prescribing Indicator

Prescribing Indicator Result WHO/INRUD Standard

Average no of drug per prescription 4.31 ± 1.51 ≤3
Percentage of drug prescribed by generic name 7.7% 100%
Percentage of encounters with injections 38.71% ≤ 10%
Percentage of patient encounters with an antibiotic prescribed. 100% ≤ 30%
Percentage of drugs prescribed from the national EDL or the facility’s formulary. 100% 100%

Table 8: Appropriateness on antibiotics

Criteria Appropriateness Marginally Appropriate Inappropriate MAI
Indication 124 3 13 42
Effectiveness 89 45 6 63
Correct Dosage 78 33 29 91
Correct Direction 138 2 2
Practical 119 10 11 32
Drug-Drug Interaction 126 0 14 28
Drug-Disease Interaction 140 0 0
Duplication with other drug 131 0 9 9
Duration of therapy 113 0 27 27
Expensiveness 110 0 35 35
Average Score 11.48 9.3 1.39 3.29

REFERENCES 19. Levin KA. Study design III: Cross-sectional studies. Evid Based Dent 2006;7:24-5.

1. Gutiérrez-Tarango MD, Berber A. Safety and Efficacy of Two Courses of OM-85 BV in
the Prevention of Respiratory Tract Infections in Children During 12 Months. Chest
2001;119:1742-8.
2. Mishra H, Mishra R, Mondal A. Prescription pattern of antimicrobial drugs in pediatrics
outpatient department of a tertiary care teaching hospital of North India. Int J Basic and
Clinical Pharmacol 2014;3:1.
3. Duwadi S. Pattern of antimicrobial prescription and its cost analysis in respiratory tract
infection. Kathmandu University J Sci 2005;1:1-9.
4. Quazi SA, Rehman GN, Khan M. Standard management of acute respiratory infections in a
children’s hospital in Pakistan:impact on antibiotic use and case fatality. Bulletin of the World
Health Organization 1996;74:501-7.
5. Khalil GM, Alghasham AA, Abdelraheem YF. Effect of Establishment of Treatment Guidelines
on Antibiotic Prescription Pattern for Children with Upper Respiratory Tract Inf Life Sci. J
2012;9:481-6.
6. Prabhakar TS, Vital Rao NS. A Study on Antibiotic Prescriptions for Upper Respiratory Tract
Infection (Urtis) in Childrens at a Tertiary Care Teaching Hospital. Res J Pharmaceuti Biolo
and Chem Sci 2015;6:813-9.
7. Boloursaz MR, Lotfian F, Aghahosseini F, Cheraghvandi A, Khalilzadeh S, Farjah A, et al.
Epidemiology of Lower Respiratory Tract Infections in Children. J Comprehensive Pediatri
2013;4:93-8.
8. JEETACAR. The use of antibiotics in food-producing animals. Commonwealth of Australia
1999.
9. Watson RL, Scott F, Dowell D, Jayaraman M, Keyserling K, Kolczak M, et al. Antimicrobial
Use for Pediatric Upper Respiratory Infections: Reported Practice, Actual Practice, and Parent
Beliefs. Pediatri 1999;104:1251-9.
10. Wutzke SE, Artist MA, Kehoe LA, Fletcher M, Mackson JM, Weekes LM, et al. Evaluation of
a national programme to reduce inappropriate use of antibiotics for upper respiratory tract
infections: effects on consumer awareness, beliefs, attitudes and behaviour in Australia. Health
Promot Int 2007;22:53-64.
11. Alumran A, Hurst C, Hou XY. Antibiotics Overuse in Children with Upper Respiratory Tract
Infections in Saudi Arabia: Risk Factors and Potential Interventions. Clinical Med Diagno
2012;1:8-16.
12. Johnston L. Rational use of antibiotics in respiratory tract infections. South African
Pharmaceut J 2012;79:34-9.
13. O’Donnell O. Access to health care in developing countries: breaking down demand side
barriers. Cadernos Saúde Pública, Rio de Janeiro 2007;23:2820-34.
14. Thomas MF, Hadley JA. Rational Use of Antibiotics to Treat Respiratory Tract Infections. The
Am J Manag Care 2002;8:713-27.
15. Akkerman AE, Kuyvenhoven MM, van der Wouden JC, Verheij TJ. Determinants of antibiotic
overprescribing in respiratory tract infections in general practice. J Antimicrob Chemother
2005;56:930-6.
16. Prajapati V. Study of prescribing patterns of antimicrobial agents in the paediatric wards at
tertiary teaching care hospital, Gujarat. Int J Pharmaceuti Sci and Res 2012;3:2348-55.
17. Pichichero ME. Understanding antibiotic overuse for respiratory tract infections in children.
Pediatri 1999;104:1384-8.
18. Gyssens I. Antibiotic policy. International Journal of Antimicrobial Agent 2011;38:11-20.
20. Barroga EF. Research study designs: an appraisal for peer reviewers and science editors. Eur
Sci Editing 2013;39:44-5.
21. Dubey A, Palaian S, Shanakar P, Mishra P, Prabhu M, Bhandari RB, et al. Introduction to
medication errors and the error prevention initiatives in a teaching hospital in Western Nepal.
Pakistan J Pharmaceuti Sci 2006;19:244-51.
22. Hanlon JT, Schamader KE, Samsa GP, Weinberger M, Uttech KM, Lewis IK, et al. A Method
For Assessing Drug Therapy Appropriateness. J Clinical Epidemiolo 1992;45:1045-51.
23. Samsa GP, Hanlon JT, Schmader KE, Weinberger M, Clipp EC, Kim U, et al. A Summated Score
For The Medication Appropriateness Index: Development And Assessment Of Clinimetric
Properties Including Content Validity. J Clinical Epidemiolo 1994;47:891-6.
24. Munir S. Acute Respiratory Infection among Children aged 2 Month to 5 Years: Do Children
with Initially “No Pneumonia” Progress to Pneumonia? Annals of Pakistan Institute of Med
Sci 2009;5:154-7.
25. Rijal P, Shrestha S, Upadhyay S. Profile of acute lower respiratory tract infection in children
under fourteen years of age at Nepal Medical College Teaching Hospital (NMCTH). Nepal
Med College J 2011;13:58-61.
26. Dirce MG, Duarte BC. Clinical profile in children under five year old with acute respiratory
tract infections. J de Pediatria 2000;76:207-12.
27. Komaroff AL, Robb-Nicholson C, Dunaif A. Women’s health Harrison’s principles of internal
medicine. United Kingdom. McGraw Hill 2001;21-5.
28. Peter AM, Robert A, Greenberg M, Keyes LM, Lisa LaVange MP, Robert S, et al. Lower
Respiratory Illness in Infants and Low Socioeconomic Status. Am J Public Health
1992;82:1119-26.
29. Ramesh L, Sai Sangeeta S, Hussain Y Sr. Analysis of Antimicrobial Prescriptions in Pediatric
Patients in a Teaching Hospital. Asian J Pharmaceutical and Clinical Res 2012;5:124-8.
30. Kailash T, Shakti S, Sheela B, Damodar B, Chaudhary RK. Prescribing Pattern Of Antibiotics
In Pediatric Hospital In Chitwan District In Nepal. World J Pharmacy and Pharmaceutic Sci
2015;4:1631-41.
31. Sharma M, Damlin A, Pathak A, Lundborg CS. Antibiotic Prescribing among Pediatric
Inpatients with Potential Infections in Two Private Sector Hospitals in Central India. PLoS
ONE 2015;10:1-12.
32. Palikhe N. Prescribing Pattern of Antibiotics in Paediatric Hospital of Kathmandu Valley.
Kathmandu University Med J 2004;2:31-6.
33. Forough A, Hosseini S, Jabbari S. Antibiotic utilization evaluation of inpatient and outpatient
prescriptions in a rural general hospital in Iran. Int J Basic and Clinical Pharmacol 2015:531-6.
34. El-Ashmony SMA. Different Patterns of Inappropriate Antimicrobial Use: A Cross Sectional
Study. Life Sci J 2013;10:216-22.
35. David RN, Jeffrey H, Ellen RW, Kelleher KJ. Antibiotic Prescribing by Primary Care Physicians
for Children With Upper Respiratory Tract Infections. Archives of Pediatrics and Adolescent
Med J 2002;156:1114-9.
36. Lorna MW, Maria C, Cunningham S. Clinical pharmacist evaluation of medication
inappropriateness in the emergency department of a teaching hospital in Malta. Pharmacy
Practice 2012;10:181-7.
37. Kadir A, Mishra P, Angsulee N. Appropriateness of Antibiotic Use in Enteric fever inpatients
in Tertiary Care Hospitals in Western Nepal: A Cross-Sectional Study. Nepal J Epidemiolo
2013;3:236-42.

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